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Sources: 2004 report by the U.S. Commission on Civil Rights, 2012 National Cancer Institute

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When her husband was laid off in 2010 from his engineering job and the couple lost his insurance, Anna Edwards said her monthly prescription bill quadrupled to almost $1,200 and she was forced to abandon some medications.

"It's like having to play Russian roulette every day and gamble on it and pray," she said. "I've had a stroke. I have a blocked coronary artery. Total blockage on the left side."

But the U.S. government made treaty commitments to provide Edwards, a San Juan Pueblo, and other Native Americans from federally recognized tribes with health care regardless of financial situation.

In Houston, it's an unfulfilled promise. Of the 10 U.S. cities with the largest American Indian populations, Houston is the only one without an Indian Health Service facility, according to a census data analysis by the Native American Health Coalition.

The coalition contends this often leaves the Houston area's 70,000 Native Americans - a population that has almost doubled in the past decade - without culturally sensitive, cost-effective and preventative health care.

"Native people typically get their diagnosis later and their mortality is greater than any other group for a lot of diseases because they don't have that easy access to preventative care," said Board Chairwoman Deborah Scott, a Cherokee.

Even as Indian Health Service struggles to meet commitments elsewhere, Scott hopes to confront Native American health disparities by bringing a clinic, or at least funding, to Houston. The effort has become a rallying point for greater recognition of the city's growing American Indian community.

Higher mortality rates

Although Houston is home to many world-class medical facilities, Native Americans access preventative care less often and have higher mortality rates for diabetes, some forms of cancer and other illnesses, according to federal health studies.

When the uninsured do access care, they're most likely to visit an emergency room or to drive to IHS clinics in Dallas or on the reservations that anchor their tribes, reports the coalition. Edwards herself planned to drive back to her people's home in New Mexico, where she could access cheaper care and prescriptions, but travel costs were too high. She went without.

Almost 20 percent of Houston-area Native Americans make less than $15,000 a year, and 40 percent earn less than $35,000, often making health care a luxury, according to the Census' American Community Survey.

The primary reason for delayed care is the same as for many other Americans - unaffordable costs - but Native Americans say they face additional barriers.

Three tribes are federally recognized in Texas, but they only received this recognition and a political voice in the past 40 years. Members of the other 25 tribes in Houston arrived from out-of-state and have faced challenges collaborating.

Edwards said this made American Indians an almost invisible population in the Houston metro area, even though census data shows their population growth in Harris County leads counties nationwide.

Every tribe in Houston has a unique set of traditions, beliefs and histories, said Scott, but some underlying similarities help explain challenges they face within the health care system.

"There are clinics that aren't familiar with native people and aren't open to how native people think," coalition leader, she said.

Some fear doctors will reject traditional healing methods, which were illegal in parts of the country until a 1978 federal law affirmed the right.

Even expectations of a patient-doctor relationship are different in many Native American cultures, leading to poor communication.

The Native American Health Coalition said it has seen some improvement after hosting sensitivity training for area medical professionals, such as the Houston Health Department including Native Americans in its long-term health care planning.

Beyond increased sympathy, Scott said the changes had little impact.

She and others hoped for more substantive changes after Houston was included in an extensive national study of urban Indians by Indian Health Service last fall.

Wolf has seen Congress incrementally increase appropriations to the service and Obama sign the Affordable Care Act, which included a permanent reauthorization of treaty commitments; and she has strengthened partnerships with other health agencies as part of Obama's push for increased collaboration.

"One of the benefits of the partnerships is maximizing limited federal resources," Wolf said. "But the quality of health care is just that much better, the more we work together."

Yet, Wolf said it remains unlikely the service will establish a new urban program in Houston, in part, because the 33 existing ones are so underfunded.

Today, nearly 80 percent of Native Americans live off-reservation, but only about 1 percent of Indian Health Service funding is dedicated to urban programs.

Even on reservations, it's common for surgery patients to wait months, and for tribal members to joke that they try not to get sick after June because that's when funds run out for some treatment programs each year.

"It sounds like a handout," Scott said of Indian Health Service care. "But it's free minimal health care. They do the best they can, but we've got rationed health care."

Wolf said she hopes to help the Native American Health Coalition seek federal grants outside of Indian Health Service to help care for Houston Native Americans, but that alternative has divided backing.

Scott supports any solution to improve care and said an alternative to a bricks-and-mortar clinic could lead to a new model of urban Indian care. "The time is ripe to do something creative in Houston and set the stage for where we're going in the future," Scott said.

She said it is important to recognize tribal sovereignty and that the federal government is falling short of treaty obligations: